Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buckingham At Norwood, The during CMS and state inspections, most recent first.
Medication administration and documentation errors affected several residents. One resident’s insulin was frequently given outside the ordered time window, another resident’s routine pain meds were often late, and two residents receiving controlled meds had MAR and controlled substance record discrepancies, including missing signatures, lack of documented effectiveness, and entries showing the wrong tramadol strength being signed out.
A resident at risk for falls was repeatedly found with the call device on the floor under the bed and out of reach while the resident was in the doorway or lying in bed. The resident said they did not know where the call device was and needed it for help. The record showed altered mental status, difficulty walking, dementia, and a fall risk care plan that included providing a working and reachable call device; the facility policy stated the call light should be accessible when in bed.
A resident with dementia, difficulty walking, unsteadiness on feet, and a prior R femur fracture sustained an unwitnessed fall and was found on the bathroom floor with blood on the face and floor. Although a post-fall assessment was documented later that day, no further shift-by-shift assessments or neuro checks were documented for the required 72-hour period, despite the DON confirming the facility policy required ongoing observation and documentation after an unwitnessed fall.
A resident with DM2, obesity, HTN, and moderate cognitive impairment was ordered to be weighed daily with provider notification for significant weight gain, but the record showed weights were missed on most days over a 59-day period. The EHR documented only a few weights, there was no documentation that the weights were discussed with the provider, and the RN and DON confirmed the daily weight order was not followed.
A resident with hemiplegia, dementia, severe cognitive impairment, and hospice services had a PRN oxygen order written as 2-6 LPM via NC for SOB. Survey review found the order was not clarified to a specific LPM, and the RN/UM and DON acknowledged that oxygen orders should specify a set flow rate rather than a range.
The facility failed to notify CMS and receive authorization for a facility name change. Surveyors observed the outside sign using the Excelcare name, and the LNHA stated the name change had been sent to the state but not completed through CMS. The DON’s business card and the Facility Assessment also used the Excelcare name, and a letter showed written notice to the Assistant Commissioner about new management, but no CMS approval was provided.
A non-certified Nursing Aide was assigned independent resident care duties without completing required training and competency evaluations. Despite being hired as a Hospitality Aide, the aide provided direct care, including bathing and feeding, without proper oversight or documentation of training completion. Interviews revealed a lack of oversight and documentation regarding the aide's training and competency.
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly QAPI meetings, potentially affecting all 156 residents. The LNHA could not confirm when the Regional Infection Preventionist Nurse (RIPN) began as the IP. The DON provided attendance sheets showing the IP's absence, confirmed by the RIPN. The LNHA admitted non-compliance with the requirement for the IP to be dedicated solely to the IPCP, and the QAPI Plan lacked information on the committee's composition.
The facility failed to complete reference checks for five out of eight newly hired staff members, including RNs and CNAs, before their start date. The HRRD confirmed the oversight, despite the facility's policy requiring reference checks as part of the new hire process.
The facility failed to follow physician orders for medication administration, resulting in multiple medication errors. Residents received medications despite vital signs being outside prescribed parameters, and medications were left at the bedside for a resident's representative to administer, contrary to policy.
A facility failed to properly store and label medications, as observed in a resident's room and across multiple medication carts and storage rooms. Unordered medications were found in a resident's room, and medication carts contained undated and unidentified medications. Additionally, discrepancies in refrigerator temperature logs were noted. The facility's policy lacked guidelines for dating opened medications and handling loose or unlabeled medications.
A facility failed to provide timely breakfast service and maintain privacy during a medical consultation. One resident waited for their breakfast tray while others were served, and an eye doctor attempted to conduct an examination in a dining area, prompting intervention by the RN/UM. These actions violated the facility's policies on meal service and resident rights.
The facility failed to submit MDS assessments within the required timeframe for three residents, as identified during a survey. The assessments, crucial for managing resident care, were completed late for residents with severe cognitive impairments and other health conditions. The MDS Coordinator acknowledged the delay in completing these assessments.
The facility failed to accurately document the vaccination status of two residents in the MDS, leading to discrepancies between the MDS records and the residents' consent forms. The MDS inaccurately indicated that vaccines were not offered, while consent forms showed that the residents' representatives had refused the vaccines. This deficiency was confirmed through interviews with facility staff.
A facility's IDT failed to involve a resident in their care planning and discharge process, leading to a deficiency. The resident, who was independent with activities of daily living, expressed a desire to be discharged but was not invited to care plan meetings. The facility's documentation did not reflect the resident's participation in care planning or any follow-up actions for discharge, despite the resident's expressed wishes.
A facility failed to conduct routine weekly skin checks for a resident, leading to a delay in identifying ulcers on the resident's right foot. The resident, who had multiple medical conditions and required assistance with daily activities, was found with wounds that had serosanguineous drainage. The lack of documentation and failure to perform routine skin checks contributed to the delay in identifying the resident's wounds, which were eventually treated after the resident was sent to the hospital for further evaluation.
Two residents receiving respiratory care experienced deficiencies in equipment storage and infection control. One resident's nebulizer mask was improperly stored, while another resident's contact precaution status was outdated, leading to improper PPE use by staff. Facility policies on nebulizer therapy and transmission-based precautions were not followed.
The facility failed to provide sufficient nursing staff and timely incontinence care, as observed during a survey. Staffing levels were inadequate, with one CNA responsible for a high number of residents, particularly on weekends. Two residents were found with soaking wet diapers, indicating a failure to adhere to the facility's incontinence policy. Despite being informed, the facility management did not refute the findings.
The facility failed to post accurate daily Nursing Home Resident Care Staffing Reports, with discrepancies noted in CNA numbers and census figures. The Unit Clerk, covering for the Staffing Coordinator, used previous day's data to estimate current staffing, leading to inaccuracies. Management was informed but did not refute the findings.
A resident with Alzheimer's Disease did not receive their prescribed Seroquel 12.5 mg at the scheduled time due to the medication's unavailability in the med cart. The LPN acknowledged the issue and contacted the pharmacy for an urgent delivery. The medication was eventually administered later in the day. The deficiency was reported to the facility's administration.
A resident with chronic kidney disease was prescribed Vancomycin for suspected C-diff infection, but lab tests were negative. Despite this, the antibiotic was continued without documented justification, violating the facility's Antibiotic Stewardship Program Policy. Late entries in the medical record were made after surveyor inquiry, indicating a lack of proper documentation and reassessment.
Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to accurately document and administer medications in accordance with physician orders for multiple residents. One resident with diagnoses including type 2 diabetes, dementia, and chronic kidney disease had insulin orders for scheduled administration at specific times, but the medication administration record and audit summary showed numerous doses were given more than one hour after the ordered time. The surveyor observed one insulin dose administered at 9:17 AM for an 8:00 AM order, and the DON acknowledged that nurses should have administered insulin within an hour of the ordered time. Another resident with rheumatoid arthritis and osteoarthritis had scheduled pain medications ordered for morning, midday, and evening administration. Survey observations and staff interviews showed routine medication passes were running late, and the facility’s audit report documented numerous late administrations of the resident’s pain medications during the month reviewed. The surveyor also found that some medications scheduled for the beginning of the morning shift were frequently documented as being administered after 2 PM. The LPNs and RN interviewed stated it was difficult to complete the medication pass within the 2-hour window, and the DON confirmed the late administration had become routine and that the physician had not been made aware of the late doses. For a resident receiving alprazolam, the controlled substance removal record and the MAR did not match. The surveyor found doses signed out on the controlled substance record without corresponding MAR documentation on some dates, and on another date the MAR lacked documentation of effectiveness as required by the care plan. The DON acknowledged that the expected process was to sign the controlled substance record when the medication was removed and to sign the MAR right after administration, and also acknowledged that effectiveness should have been documented. For another resident receiving tramadol, the MAR and controlled substance administration records contained multiple discrepancies. Several MAR entries were left blank and unsigned, and the controlled substance records repeatedly showed nurses signing out tramadol 50 mg when the resident’s order was for tramadol 25 mg. The surveyor and DON reviewed multiple dates in February and March where the controlled substance records reflected the wrong strength being documented as dispensed, while the MAR showed the 25 mg dose as administered. The DON stated the records reflected that tramadol 50 mg was administered instead of tramadol 25 mg, and the facility’s records did not show documentation of disposal or a second nurse witness for split tablets.
Call Device Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a call device was positioned within reach of a resident who was at risk for falls. Resident #59 was observed standing in the doorway of the room and told the surveyor that help was needed because water had spilled in the room, but the resident did not know where the call device was. The call device was observed on the floor under the bed near the roommate's bed. The same resident was later observed lying in bed on two additional occasions, and each time the call device was again found on the floor under the bed near the roommate's bed. The resident stated they did not know where the call device was and said it was important to have it in case it was needed. The resident's record showed diagnoses of altered mental status, difficulty walking, and dementia, and the care plan included a fall risk intervention for providing a working and reachable call device. The facility's policy stated the call light should be accessible to the resident when in bed.
Failure to Continue Post-Fall Assessments
Penalty
Summary
The facility failed to continue assessing a resident after an unwitnessed fall to determine whether there were any adverse effects from the event. Resident #80 had diagnoses that included a fracture of the right femur, dementia, difficulty walking, and unsteadiness on feet. The resident’s annual MDS reflected moderate cognitive impairment, wheelchair use for mobility, and a need for assistance with transfers. The resident was found on the bathroom floor with blood on the face and floor and was unable to provide details about what occurred. A nursing note documented a post-fall assessment later that day, but the EHR did not show any further follow-up assessments after that entry. The DON confirmed the facility’s fall prevention policy required the nurse assigned to the resident to document observations every shift for 72 hours after an unwitnessed fall, including neurological checks and assessment of the resident’s status, and confirmed those ongoing assessments were not documented after the initial post-fall note.
Failure to Follow Daily Weight Order
Penalty
Summary
The facility failed to monitor the nutritional status of Resident #137 by not following a physician’s order to weigh the resident daily and notify the provider if the resident gained more than 3 lbs. in 24 hours or more than 5 lbs. in one week. The resident was admitted with diagnoses including type 2 diabetes, obesity, essential hypertension, and urinary retention, and the annual MDS dated 2/20/26 reflected moderate cognitive impairment. On 3/26/26, the surveyor observed the resident in bed, awake and responsive, with the call bell within reach. A review of the medical record showed that a weight was not obtained on 50 of 59 days in February and March 2026 as required by the physician’s order. The EHR reflected weights documented on only a limited number of dates, including 2/5/26, 2/8/26, 2/14/26, 2/15/26, 2/17/26, 2/18/26, 2/28/26, 3/8/26, and 3/29/26, and the record did not show that these weights were discussed with the provider during March or April 2026. The resident stated he could not recall being weighed by staff, and the RN confirmed the order for daily weights and acknowledged that weights should be assessed and documented according to physician orders. The DON also confirmed that the weights were not obtained and documented per the order on 50 of 59 days.
Unclear PRN Oxygen Order Not Clarified
Penalty
Summary
The facility failed to clarify an oxygen therapy order for Resident #16, who had diagnoses including hemiplegia and dementia and was assessed as having severe cognitive impairment with a BIMS score of 5 out of 15. The resident also had an order indicating hospice services. A physician's order dated 10/13/25 directed oxygen at 2-6 liters per minute via nasal cannula as needed for shortness of breath, but the order did not specify a single liter flow rate. Review of the March and April 2026 TAR showed the resident had not needed PRN oxygen therapy. During surveyor interview, the RN Unit Manager stated oxygen therapy orders should have a specified LPM and acknowledged the nurses should clarify the physician's order because it should not be written as a range. The RN/UM also stated there may be oxygen therapy recommendations for a range of LPM, especially for hospice residents, but agreed the order needed clarification with the physician. The DON later stated the expectation was for an oxygen therapy order to have a specific LPM and not a range, and confirmed the RN/UM clarified the order with the physician after surveyor inquiry.
Failure to Obtain CMS Approval for Facility Name Change
Penalty
Summary
The facility failed to notify CMS and obtain authorization for a change in facility name in accordance with 42 CFR 424.516. During surveyor observation on 3/26/26 at 8:55 AM, the sign outside the facility identified the building as Excelcare at [NAME] rather than [NAME] at [NAME]. When interviewed later that morning, the LNHA stated that the facility was now owned by Excelcare and that a request for the name change had been sent to the state, but the change had not yet been completed through CMS. Additional documents reviewed by the surveyor reflected the Excelcare name on the DON’s business card and on the cover pages of the Facility Assessment. On 3/27/26, the LNHA provided a letter dated February 28, 2025 showing written notification to the Assistant Commissioner regarding an agreement for new management. The survey team met with the LNHA and DON to discuss the use of the ExcelCare at [NAME] facility name without CMS approval, and no further information or documentation was provided to refute the findings.
Failure to Ensure Nursing Aide Competency Before Independent Assignments
Penalty
Summary
The facility failed to ensure that a non-certified Nursing Aide (NA #1) received the required training and competencies before being assigned independent resident care duties. NA #1 was hired as a Hospitality Aide and began independent resident care assignments shortly after, without completing the necessary training and competency evaluations. This oversight was identified for one of nine NAs reviewed, who provided direct care to residents across all five nursing units. NA #1 was hired on June 17, 2024, and began independent assignments on July 3, 2024, before being enrolled in a state-approved Nurse Aide Training and Competency Evaluation Program (NATCEP) on July 15, 2024. Despite being enrolled, NA #1 worked 69 shifts without evidence of completing the required skills and competencies. The facility's job descriptions for Hospitality Aides and Nursing Assistants clearly outlined the responsibilities and limitations, yet NA #1 was assigned tasks beyond their training, such as bathing, toileting, and feeding residents. Interviews with facility staff revealed a lack of oversight and documentation regarding NA #1's training and competency. The Director of Nursing and Human Resources staff were unable to provide evidence of NA #1's completed training or competency evaluations. Additionally, NA #1's school confirmed that they did not complete the program, further highlighting the facility's failure to ensure that all NAs were adequately trained before providing direct care to residents.
Removal Plan
- NA #1 was removed from employee schedule
- Staff education on hiring Hospitality Aides and the process for hiring and scheduling Nursing Aides
- DON reviewed all current NA onboarding requirements
- DON reviewed all NAs to confirm they had the required competency skills
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly Quality Assurance Performance Improvement (QAPI) meetings, which had the potential to affect all 156 residents currently living in the facility. During an entrance conference, the Licensed Nursing Home Administrator (LNHA) was unable to confirm when the Regional Infection Preventionist Nurse (RIPN) began serving as the facility's IP. The Director of Nursing (DON) provided QAPI attendance sheets for the last three quarters, which showed that the IP did not attend the meetings on 5/29/24, 7/23/24, and 10/22/24. The RIPN confirmed the absence of an IP in these meetings. The LNHA acknowledged that the facility did not comply with the requirement for the designated IP to be dedicated solely to the Infection Prevention Control Program (IPCP). The QAPI Plan provided by the LNHA lacked information on the composition of the QAPI Committee. During a QAPI interview, the LNHA stated that the DON reported on infection control in the absence of the IP. The facility did not provide additional information or refute the findings during the exit conference.
Incomplete Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for five out of eight newly hired staff members before their employment start date. This deficiency was identified during a review of eight randomly selected new employee files, where it was found that several staff members, including Registered Nurses and Certified Nursing Assistants, had incomplete or missing reference checks. Specifically, two RNs had only one reference check each, while three CNAs had no reference checks in their files. The Human Resources Regional Director (HRRD) acknowledged that the facility's process involved asking staff to provide additional references if initial contacts were unreachable, and personal references were required if there was no work history. However, the HRRD confirmed that reference background checks were not completed for the five newly hired staff. The facility's policy on the new hire process emphasized the importance of completing reference checks, but this step was not adhered to, leading to the deficiency.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding medication administration for several residents, leading to multiple instances of medication errors. For Resident #28, the facility did not follow the physician's order to hold hydralazine when the blood pressure was below 140, resulting in the medication being administered on several occasions despite the blood pressure being below the specified threshold. Similarly, Resident #131 received Humalog insulin even when their blood sugar levels were below the prescribed parameter of 110, indicating a failure to follow the physician's orders. Resident #117, who had severe cognitive impairment, was administered Midodrine despite having a systolic blood pressure greater than 140, contrary to the physician's order to hold the medication under such conditions. This pattern of not adhering to medication parameters was also observed with Resident #140, who received Midodrine when their systolic blood pressure was above the prescribed limit of 120. Additionally, Resident #142 was given Amlodipine and Losartan despite their blood pressure and heart rate being outside the parameters set by the physician. Furthermore, Resident #144 was found with a cup of medications left at the bedside, which were intended to be administered by the resident's representative. This practice was not in line with the facility's medication administration policy, which requires medications to be administered by licensed nurses or authorized staff. The facility's failure to ensure medications were administered according to physician orders and professional standards of practice was evident across multiple instances and residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications for one resident and ensure that medications were stored and labeled appropriately for two medication carts and two medication storage rooms across four nursing units. This was observed when a surveyor found three containers of medications, including L-Lysine, Vitamin D3, and Vitamin B12, in a resident's room without proper storage or orders in the electronic Medication Administration Record (eMAR). The Licensed Practical Nurse (LPN) was unaware of these medications being at the bedside and confirmed there were no orders for them, acknowledging that medications should not be left or stored in the resident's room. Further deficiencies were noted during inspections of medication carts and storage rooms. On one unit, a foil package of Budesonide nebulizer solution was found without a documented date of opening, and loose unidentified tablets were discovered in the medication cart. Similarly, on another unit, a box of Ipratropium/Albuterol nebulizer solution was found with an open foil packet lacking a documented opening date, along with a loose unidentified tablet. The med nurse was unable to identify the tablets and confirmed the absence of opening dates on the foil packages. The surveyor also noted discrepancies in the temperature logs of medication refrigerators, with one refrigerator showing a temperature of 30 degrees Fahrenheit, while the log recorded 40 degrees Fahrenheit. The facility's Medication Storage Policy, revised in October 2023, was reviewed and found to lack specific guidelines regarding the dating of opened medications and the handling of loose, unlabeled, or unidentifiable medications. The Consultant Pharmacist confirmed that opened foil packs should be dated and that the normal refrigerator temperature should be between 36 to 46 degrees Fahrenheit. The surveyor discussed these concerns with facility management, who acknowledged the need for proper medication storage and labeling.
Deficiencies in Meal Service and Privacy During Medical Consultation
Penalty
Summary
The facility failed to provide a dignified dining experience for residents in the 2 South dining area by not serving breakfast in a timely manner. On the morning of 10/31/24, a surveyor observed that one resident, identified as Resident #25, was seated without a breakfast tray while other residents had already received theirs. The breakfast tray for Resident #25 was on a food truck, but the Certified Nursing Aide (CNA) was occupied feeding another resident. The Quality Assurance Corporate Aide (QACA) eventually served the tray after the surveyor's inquiry, indicating a delay in service. Additionally, four residents had to wait 30 minutes for their breakfast trays, which were only served after the arrival of the second food truck. In a separate incident in the 1 South dining area, a lack of privacy was observed during a medical consultation. An eye doctor attempted to conduct an eye examination on Resident #67 in the dining room immediately after the resident finished their meal. The Registered Nurse/Unit Manager (RN/UM) intervened, instructing the doctor to conduct the consultation in the resident's room, as it was inappropriate to perform such procedures in a communal dining area. The facility's policies on serving meals and respecting resident rights were reviewed, revealing that meals should be served promptly and residents have the right to privacy and dignity. The surveyor's findings highlighted deficiencies in adhering to these policies, as evidenced by the delayed meal service and the lack of privacy during a medical consultation.
Late Submission of MDS Assessments for Three Residents
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) assessments within the required timeframe for three residents. The MDS is a critical assessment tool used to manage the care of residents, and according to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, it must be completed no later than 13 days after a resident's entry date. However, the assessments for three residents were completed late, exceeding the 13-day requirement. This deficiency was identified during a surveyor's review of the residents' records and interviews with facility staff. Resident #125 was admitted with a diagnosis of encephalopathy and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The comprehensive MDS (cMDS) for this resident was completed more than 13 days after admission. Similarly, Resident #132, admitted with unspecified dementia and other mental health issues, had a cMDS completed late, with a BIMS score showing severely impaired cognition. Resident #212, diagnosed with rhabdomyolysis, also had a cMDS completed beyond the required timeframe, with a BIMS score indicating moderate cognitive impairment. The MDS Coordinator/Registered Nurse acknowledged the delay in completing these assessments during an interview with the surveyor.
Inaccurate MDS Documentation for Resident Vaccination Status
Penalty
Summary
The facility failed to accurately reflect the status of two residents in the Minimum Data Set (MDS), which is a critical assessment tool used for managing care in compliance with federal guidelines. For Resident #125, the MDS inaccurately documented the resident's vaccination status. The comprehensive MDS indicated that the resident had not received the influenza and pneumococcal vaccines, citing reasons such as 'not offered' and 'not eligible-medical contraindication.' However, a review of the resident's consent forms showed that the resident's representative had explicitly refused consent for these vaccinations. This discrepancy highlights a failure in accurately recording the resident's vaccination status in the MDS. Similarly, for Resident #212, the MDS inaccurately reflected that the pneumococcal vaccine was not received because it was 'not offered,' despite the resident's representative having refused consent for the vaccine. The surveyor's interview with the Regional Infection Preventionist Nurse and the MDS Coordinator/Registered Nurse confirmed the incorrect MDS coding. The facility's failure to accurately document the vaccination status in the MDS assessments for these residents constitutes a deficiency in maintaining accurate and compliant resident records.
Failure to Involve Resident in Care Planning and Discharge Process
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to ensure that the care plan for a resident was revised to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The deficiency was identified during a survey when a resident expressed concerns about their discharge plans. The resident, who had been in the facility for several months for rehabilitation therapy, was independent with activities of daily living and did not have a place to stay outside the facility. Despite expressing a desire to be discharged, the resident was not involved in the care planning process, and there was no documentation of the resident being invited to care plan meetings. The resident's medical records revealed that they had a history of atherosclerotic heart disease, hypertension, schizophrenia, and type 2 diabetes mellitus. A quarterly MDS assessment indicated that the resident was cognitively intact. However, the facility's documentation did not show that the resident was invited to participate in care plan meetings or that their wishes regarding discharge were considered. The social worker (SW) responsible for the resident's care planning did not document any follow-up actions or referrals for the resident's discharge planning, despite the resident's expressed desire to leave the facility. The facility's policies on discharge planning and comprehensive care plans require that residents be involved in their care planning and that any decisions regarding discharge be documented. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation of the resident's participation in care planning and the absence of referrals for discharge. The facility's failure to involve the resident in their care planning and to document the discharge planning process led to the identified deficiency.
Failure to Conduct Routine Skin Checks Leads to Delayed Wound Identification
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policies. This deficiency was identified during a review of a facility-reported event involving a resident who was found with ulcers on the right foot. The investigation revealed that weekly skin checks had not been completed for two weeks prior to the identification of the wounds, which were noted with serosanguineous drainage. The resident was subsequently examined by a nurse practitioner, who ordered x-rays, intravenous antibiotics, and various consults before the resident was sent to the hospital emergency room for further evaluation. The resident, who had a history of quadriplegia, major depressive disorder, contractures, peripheral vascular disease, neuromuscular dysfunction of the bladder, and hypertension, was cognitively intact and required assistance with activities of daily living. The facility's records indicated that there was only one documented skin evaluation for the month of August, despite a physician's order for weekly skin assessments. The lack of documentation and failure to perform routine skin checks contributed to the delay in identifying the resident's wounds. Interviews with facility staff, including the LPN who cared for the resident, revealed that the resident was generally cooperative with care but occasionally refused it. The LPN relied on CNAs to notify them of any skin impairments during daily care, but the weekly skin assessments were not consistently documented. The Director of Nursing and the Licensed Nursing Home Administrator, who were not part of the administration at the time of the incident, were unable to provide additional information regarding the investigation conducted by the previous administration.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to ensure proper storage and handling of respiratory equipment for two residents receiving respiratory care. One resident, who was cognitively intact and admitted for rehabilitation, had a nebulizer mask that was not stored in a plastic bag as required by facility policy. The nebulizer mask was observed on top of a nightstand, which was confirmed by the resident and a Licensed Practical Nurse (LPN) as improper storage. The resident's medical records indicated a history of asthma, heart failure, and hypertension, and the resident received respiratory therapy for 225 minutes over a seven-day period. Another resident, who had a tracheostomy and was on contact precautions for MRSA, was observed with a nebulizer mask not stored properly. The resident's room had a contact precaution sign, but a Recreation Aide (RA) entered without wearing personal protective equipment (PPE) and did not perform hand hygiene upon exiting. The LPN later clarified that the resident's contact precaution status was outdated, and the sign should have been for Enhanced Barrier Precautions (EBP) instead. The resident's medical records showed a history of intracerebral hemorrhage, chronic respiratory failure, and tracheostomy status, with respiratory therapy provided for 375 minutes over a seven-day period. The facility's policies on nebulizer therapy and transmission-based precautions were not followed, leading to improper storage of respiratory equipment and failure to adhere to infection control measures. The facility's Infection Preventionist Nurse confirmed the deficiencies and acknowledged that the nebulizer masks should have been stored in bags when not in use. Additionally, the RA's failure to follow posted signs for contact precautions was noted, although it was later clarified that the resident was not actively infected with MRSA.
Inadequate Staffing and Incontinence Care Deficiency
Penalty
Summary
The facility failed to ensure sufficient nursing staff and timely incontinence care for residents, as observed during a survey. On multiple occasions, the staffing levels were inadequate, with one CNA responsible for a high number of residents, particularly during weekend shifts. For instance, on a specific day, the Penthouse unit had only one CNA for 18 residents, and similar staffing issues were noted across other units. This staffing shortage was confirmed by interviews with staff and review of the Nursing Home Resident Care Staffing Report (NHRCSR), which showed high staff-to-resident ratios, especially during night shifts. The deficiency was further evidenced by the condition of two residents during an incontinence care tour. Resident #67 was found with a strong smell of urine emanating from their room, and upon inspection, was discovered to be wearing double diapers, which were soaking wet, along with the incontinence pads and bed sheets. The CNA attending to Resident #67 confirmed being the only CNA on duty for the shift. Similarly, Resident #214 was found with a soaking wet diaper, and the CNA responsible for their care also reported being the sole CNA for the unit, managing 37 residents. Interviews with the nursing staff revealed that the issue of insufficient staffing, particularly on night shifts and weekends, was a recurring problem. The facility's incontinence policy, which mandates appropriate treatment and services for incontinent residents, was not adhered to, as evidenced by the condition of the residents. Despite being informed of these issues, the facility management did not provide additional information or refute the findings during the exit conference.
Inaccurate Staffing Reports in LTC Facility
Penalty
Summary
The facility failed to post an accurate Nursing Home Resident Care Staffing Report (NHRCSR) daily for three out of seven days, which could affect the knowledge of staff availability for resident care. On multiple occasions, discrepancies were noted between the posted staffing reports and the actual staffing levels. For instance, on one day, the posted report indicated 13 CNAs for the day shift, while the actual schedule showed only 11 CNAs. Additionally, the census numbers on the posted reports did not match the actual census numbers provided by the Registered Nurse Supervisor. The inaccuracies in the staffing reports were attributed to the process used by the Unit Clerk, who was temporarily covering for the full-time Staffing Coordinator. The Unit Clerk was using the previous day's staffing information to estimate the current day's staffing levels, leading to discrepancies. Furthermore, the Unit Clerk incorrectly counted two noncertified nursing aides (NAs) as equivalent to one CNA, which contributed to the inaccurate staffing numbers. The facility's management, including the Licensed Nursing Home Administrator and the Director of Nursing, were informed of these discrepancies. The Regional Clinical Operation acknowledged that the posted NHRCSR should be accurate and not estimated. Despite being aware of the issues, the facility did not provide additional information or refute the findings during the exit conference with the survey team.
Medication Unavailability Leads to Delayed Administration
Penalty
Summary
The facility failed to administer medication to a resident due to the unavailability of the prescribed drug. During a medication administration observation, an LPN was unable to provide Seroquel 12.5 mg to a resident diagnosed with Alzheimer's Disease, as the medication was not available in the medication cart. The LPN acknowledged the absence of the medication and informed the surveyor that she would contact the pharmacy for an urgent delivery. The resident's medical record indicated a severely impaired cognitive status with a BIMS score of 07 out of 15. The electronic Medication Administration Record (eMAR) showed that the Seroquel was not administered at the scheduled time but was given later in the day once it became available. The last delivery of the medication was recorded on 10/24/24, indicating a lapse in ensuring the medication was restocked in a timely manner. The deficiency was reported to the Director of Nursing, the Licensed Nursing Home Administrator, and the Regional Director of Operations.
Failure to Discontinue Unnecessary Antibiotic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. The resident, who was admitted with chronic kidney disease and a urinary tract infection, was prescribed Vancomycin for suspected Clostridium difficile (C-diff) infection. However, a lab test conducted after the initiation of Vancomycin treatment returned negative for C-diff toxins. Despite this, the antibiotic treatment was continued without documented justification for its necessity, as required by the facility's Antibiotic Stewardship Program Policy. The surveyor's investigation revealed that the physician's progress notes justifying the continued use of Vancomycin were entered as late entries after the surveyor's inquiry. The Regional Infection Preventionist Nurse confirmed that there was no documented reason for continuing the antibiotic in the resident's medical record or the facility's antibiotic stewardship documentation. The facility's policy mandates reassessment of empiric antibiotics after 2-3 days, but this was not adhered to, leading to the administration of an unnecessary medication.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,348 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Norwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jewish Home At Rockleigh | 1.7 mi | ★★★★★ | 0 | 0 |
| Careone At Valley | 3.2 mi | ★★★★★ | 6 | 0 |
| Emerson Health Care Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Family Of Caring At Park Ridge Llc | 4.2 mi | ★★★★★ | 3 | 0 |
| St Cabrini Nursing Home | 4.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Buckingham At Norwood, The.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.